STATEMENT OF PURPOSE - St Luke's Hospice€¦ · STATEMENT OF PURPOSE . Issue Date: Jan 2018 ....

STATEMENT OF PURPOSE Issue Date: Jan 2018

Review Date: Jan 2019 Issue Number: 21

St Luke’s Hospice Plymouth

Registered Charity Number 280681 Registered Office: Stamford Road, Turnchapel, Plymouth, Devon PL9 9XA

T:\QUALITY&COMPLIANCE\CQC\SOP\SOP v21.doc Version No. 21 AO: Chief Executive of 31 Date of Implementation: Jan 2018 Drafted by: Frankie Dee Revision due by: Jan 2019

Document History: St Luke’s Statement of Purpose

Version & Date By Comments

V21 2018/01 JF Dee Scheduled review. Updating of Trustees and contact details.

V20 2017/01 JF Dee Appointment of CE and 1 new Director. Complaints Policy updated. Removal of 1 Trustee. Updated key personnel details

v19 2016/07 JF Dee Removal of Brooklands as a site where regulated activities are undertaken. Update of organisational chart

v18 2016/01 JF Dee Change of Nominated Individual. Removal of Chief Executive and Director of Income Generation. Re-wording of Crisis Team services. Up-dates to staff qualifications, Board of Trustees and Organisational Chart.

v17 2015/07 JF Dee Change of business address from Pearn to Brooklands. Lymphoedema service moved to Turnchapel. Crisis Team moved to Brooklands

v16 2015/01 JF Dee Reformatting. Change in focus of Service towards Community; reduction of in-patient beds from 20 to 12; addition of Crisis Team; Vision updated; New role of Associate Director added; list of Trustee’s updated

Issued to:

Signed original: Policies Files in Q&C Admin Office Electronic Copies Q&CD Policies Master Folder Public Folders Intranet

Summary Information/Record of Approval

Policy Area: Hospice Management

Accountable Person: Chief Executive

Originated by: Head of Quality & Compliance


Review Group: Date Reviewed:

Senior Management Team December 2017

Approved by: Chief Executive

Signature:

Date of Approval:

Last date for review: January 2019

Related Policies: All


Aims and Objectives of St Luke’s Hospice Plymouth Services The aim of St Luke’s is to provide specialist care and support to people with life limiting illnesses, and their carers. The emphasis of our services (Hospice without Walls) is to provide excellent care in the place the patient wishes to be cared for. St Luke’s works in partnership with the local NHS Clinical Commissioning Group, Acute Trust and other care providers to deliver care which is commissioned by and additional to that provided by the NHS. Our vision as an organisation is a community where no person has to die alone, in pain or distress Personnel St Luke’s provides a safe, motivating and supportive environment for all staff (paid and unpaid) by ensuring appropriate recruitment, personal development, training and performance review together with effective leadership. Written policies and procedures are in place to support staff across all areas of service provision. Finance St Luke’s is committed to ensuring that the charity will be financially viable for the purpose of achieving its service aims and objectives in both the short and the long term. A copy of the latest financial statements is available on request from the Director of Finance. Please ask at reception. Premises and Equipment St Luke’s ensures that premises and equipment are of a design, layout, location and maintenance suitable to enable achievement of the service aims. Risk Management St Luke’s ensures that all risks associated with the operation and services of the charity are identified, assessed and managed appropriately. Strategy St Luke’s is working with the other local providers of End of Life Care, and those responsible for commissioning services for the local population, to design, fund and deliver an effective strategy for the care of all local people with life limiting illness and their families. Fundraising and Publicity St Luke’s encourages voluntary financial, and in kind, support from the community it serves; through publicity, awareness campaigns and fundraising activities. This support will enable its services to be maintained and further developed for both the short and the long term. St Luke’s is a member of the Fundraising Standards Board. Legal St Luke’s is committed to fulfilling its legal obligations under Charity, Company, Health and Safety, Employment, Care Quality Commission and other relevant legal requirements in the provision of its services and activities.


2. Registered Provider and Registered Manager The establishment is run by St Luke’s Hospice Plymouth, which is a registered charity, number 280681 and a company limited by guarantee, number 1505753. St Luke’s Hospice Plymouth, the Registered Provider, operates from:

St Luke’s Hospice Stamford Road Turnchapel Plymouth PL9 9XA Telephone no: 01752 401172 Fax no: 01752 481878 Web site: stlukes-hospice.org.uk

The organisation is regulated for the following activities: o Treatment of disease, disorder and injury; o Diagnostic and screening procedures. The Nominated Individual is the Director of Clinical Services and the Registered Manager is the Head of Quality & Compliance. Details of relevant qualifications of these and other key personnel can be found in appendix B. The address for Service for these individuals is:- St Luke’s Hospice

Stamford Road Turnchapel Plymouth PL9 9XA Telephone no: 01752 401172 Fax no: 01752 481878

The charity is directed by a Board of Trustees, led by the Chairman. The Senior Management Team, which consists of the Chief Executive and the 4 Directors, report to the Board of Trustees. Trustees sit on a number of key committees and groups. See appendix C for details of Trustees and Committees. The Multi-professional Clinical team includes Medical and Nursing staff, Social Workers, Occupational Therapists and a Physiotherapist. The members of this clinical team have a wide range of specialist palliative care and generic skills, abilities and educational qualifications. The Clinical team is supported by managers, administration, clerical, accountancy, catering, housekeeping, maintenance staff, and trained volunteers. Where appropriate, staff have professional qualifications. Appendix D shows details of organisational structure.


Funding for services comes from service agreements with the local NHS Commissioners and from fundraising and charitable giving. St Luke’s employs a fundraising team. A subsidiary company, SLH Ventures Ltd. exists to facilitate trading activities. It is possible for patients to access their health records providing that it is not deemed medically detrimental to their health. St Luke’s has a policy and procedure in order to enable this. If patients wish to access their records please ask a member of staff who will assist with the process.

3. The Palliative Care Services available at St Luke's Hospice In-patient Unit • The in-patient unit is situated in the main hospice building at Turnchapel. It is on

one level and comprises both single and four-bedded rooms. Most rooms look out onto Plymouth Sound and all beds have their own television. There is free car parking and a hospice coffee shop is available with light snacks for visitors. The hospice has a no-smoking policy for staff and relatives/carers but there is a smoking room available for patients.

• The unit can admit up to 12 patients with life-limiting illness (Cancer and non-malignant disease including for example Motor Neurone disease and end stage lung disease)

• Referrals are taken from health care professionals and prioritised on the basis of patient need for symptom control, psycho-social support or terminal care

• The approach to care is holistic and centred on the needs of the individual patient. Physical, emotional, spiritual and psychosocial needs are considered. Both traditional and complementary treatments are available.

Contact details: All enquiries 01752 401172

Outpatient Care • There are Specialist Palliative Care clinics held at Derriford Hospital taking direct

referrals and doing follow-up for discharged in-patients. Appointments are made by the Clinical Administration Team on 01752 436744/735.

• There is a Pain clinic at Turnchapel taking direct referrals and follow-ups. Appointments are made by the Clinical Administration Team on the Turnchapel site on 01752 401172

• The Lymphoedema clinic (based at Turnchapel) is accessed by direct referral from a health care professional to the specialist nurse on 01752 246600.

Hospital Specialist Team Support and Management • St Luke’s Hospital Palliative Care Team operates in Derriford Hospital and is

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specialist nurses and doctors offer support, information and advice on managing pain and other symptoms for patients with life limiting illness in the hospital setting when requested by the patient’s consultant. They are based in the oncology department. The team works nine to five, seven days a week. Out of hours telephone advice is available from the medical and nursing team at the hospice Turnchapel site on 01752 401172.

• St Luke’s Hospital Service is also committed to the education of fellow health professionals in General Palliative Care and related areas, and to active staff support in difficult or distressing clinical situations.

• There are regular case conferencing meetings to provide medical support to other Hospital teams.

Community Specialist Team Support and Management • The specialist nurses and other specialist team members (including Social

Workers and Occupational Therapists) offer support, information and advice on managing pain and other symptoms for patients with life threatening illness in their own homes. The community team are based within our Brooklands site and can be contacted on 01752 964200, seven days a week, 365 days a year. After 5pm telephone advice is available from the medical and nursing team at the hospice on 01752 401172.

• There are regular case conferencing meetings to provide medical support to the Community Specialist Palliative Care Team and domiciliary visits are carried out on request.

Social Work and Occupational Therapy • The staff are there to provide support to patients and their families. They

understand and can help with the emotional, practical, financial and spiritual problems caused by illness. They will liaise with other social support services or any relevant minister if the patient requires.

• The team works with local health and social care services in order to arrange community care, nursing home care, providing advice, information and emotional support. In-patient and outpatient assessment, and home assessment prior to discharge are also available. They also provide information and advice on benefits available.

Crisis Response Team

• The Crisis team are based within our Brooklands site and can be contacted on 01752 964 200, seven days a week, 365 days a year. The team provides end- of-life care and palliative hands on nursing care support in the community at a time of crisis. Its aim is to enable patients to achieve their preferred place of care, provide care where there is a sudden deterioration and the patient is too unwell to move, and to facilitate a rapid discharge to the preferred place of care of the patient at the end of life – available up to 8pm Monday to Thursday and 24 hours a day Friday to Monday and Bank holidays.


• The Crisis Team covers Plymouth, Dartmoor and Tavistock; across to the South

Hams and Kingsbridge and into East Cornwall.

Education and Training • St Luke’s provides an extensive multi-disciplinary programme aimed at extending

palliative care skills for all who are working to support the patient, and their family, with life-threatening illness.

4. Arrangements for Consultation with patients on the operations of St Luke’s Hospice

St Luke’s ascertains and takes into account as far as is practicable, the wishes and feelings of all its patients and other users when determining the manner in which they are cared for and the services which are provided for them. The services are tailored to the requirements of individual patients, and are based on full discussion with patients of their individual care needs. On-going patient satisfaction surveys are carried out for individual service areas. Results are available from the Head of Quality & Compliance. A suggestion scheme is in place for everyone who is associated with or visits St Luke’s. Patient information encourages patients and their families to comment on services and care delivery. A key philosophy of St Luke’s is that the hospice grew from the local community who identified the need for a hospice and fundraised to build it. The people who have benefited from the care are closely involved with the service as trustees and volunteers and key to ensuring that the service is responsive to its users. Further systems to include user involvement in service planning are being developed.

5. Arrangements for Personal Contact for Patients All patients can receive and make outgoing calls at their bedside if they wish. There is also internet access available for patients if they wish to communicate in this way. Incoming post is delivered to the patient every day. Family and friends can telephone the in-patient unit for advice, support and information. Information about the patient is only disclosed with the patient’s permission. Visiting times are flexible and open but visitors are encouraged to visit between 11 am and 8 pm if possible and staff will monitor the situation to ensure that the patient’s wishes and needs are respected. St Luke’s aims to ensure that all patients and visitors can access services, and, in particular, aims to ensure access is facilitated for people of different cultural and ethnic backgrounds and those with physical or sensory disabilities, and learning difficulties.


6. Arrangements for Managing complaints/ suggestions St Luke’s is keen to improve the service provided and values feedback from those who use the service. Complaints can be made in a number of ways: There is a complaints and suggestions box in the Inpatient Unit coffee shop near the reception area on the Turnchapel site. A complaints/suggestion form can be found next to the box and placed inside once completed. A response will be given if names are left but it can be anonymous if required. Users may speak to one of the staff who is looking after them and leave a verbal complaint. Users may write to the Chief Executive at the hospice. Users may initiate St Luke’s Services complaints procedure (See Appendix E.) Users can contact the Care Quality Commission at:-

South West Region Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Telephone: 03000 616161

A monthly summary of complaints, together with the actions taken in respect of those complaints, is provided to the Senior Management Team.

7. Arrangements for respecting the Privacy and Dignity of Patients St Luke’s believes that every patient has a right to be treated with dignity and respect and has a right to privacy. All care delivery is carried out in appropriate surroundings and curtaining is used wherever necessary to preserve privacy. Private rooms are available for confidential discussions. Multi-bedded rooms are spacious and are single sex. There are en-suite facilities for all of the in-patient beds.


APPENDIX A

The Objects of the Charity The principal object of the charity, as defined in the Articles of Association, is to relieve sickness amongst people suffering from terminal illness, in particular in the City of Plymouth and the surrounding districts.

St Luke’s Vision, Guiding Principles and Values

Our Vision is a community where no person has to die alone, in pain, or in distress


St Luke’s Guiding Principles We aim for excellence and have agreed a number of principles which guide our strategy and our Action plans. We will be:

1. Innovative 2. Efficient 3. Evidence based

We will ensure that our services are:

4. Those needed by the individual and their loved ones 5. Delivered where they need them 6. Based on need not diagnosis

We will ensure that our staff will have:

7. The skills and knowledge to deliver excellent services 8. The motivation and passion to make a difference 9. The processes and structures that allow them to work in an integrated way

We will:

10. Ensure public and user involvement and consultation 11. Work in partnership with the NHS, Social Services and other stakeholders 12. Avoid duplicating services available elsewhere 13. Provide education and support to those caring for patients at the End of Life 14. Develop new sources of income to support new initiatives 15. Build our reserves to six months expenditure to safeguard our services

The Values which are the foundation for our work Our service will be caring and holistic. We will be honest and we will respect and listen to our patients and their carers, treating everyone with courtesy, kindness and empathy. We will be passionate and visionary. We will strive at all times for a quality service that uses resources well. We give time for quality care. We achieve this by showing professionalism:

• Striving for excellence in everything we do. • Setting high standards and challenging ourselves to do our best. • Going the extra mile when necessary. • Remaining patient focused and committed to patient care. • Adopting a positive approach to our own self-development. • Being open to change to enhance quality of care. • Having the courage of our convictions. • Inspiring creativity, passion, optimism and fun.

We achieve this by showing respect:

• Taking time to say “thank you” T:\QUALITY&COMPLIANCE\CQC\SOP\SOP v21.doc Version No. 21 AO: Chief Executive of 31 Date of Implementation: Jan 2018 Drafted by: Frankie Dee Revision due by: Jan 2019

• Being fair and treating everyone with respect. • Embracing diversity; respecting the breadth of cultures, values and traditions. • Openly recognising and acknowledging the achievement of others. • Respecting the dignity and rights of all individuals in all dealings. • Welcoming the opinions and ideas of all people. • Being prepared to trust and learn from others.

We achieve this with compassion: • Giving time to listen, and giving time to care. • Being present for others without judgement. • Offering hope, comfort and support when required. • Understanding a position from others’ perspective. • Making the difference.

We achieve this with integrity:

• Being positive and realistic about our abilities. • Keeping our promises. • Communicating information honestly, openly and straightforwardly. • Maintaining high moral and ethical standards. • Being real. • Having the personal courage to take the right tough decisions. • Building trust with others through our own authenticity, open and direct dialogue

Strategic Objectives 2017-2018

1. Hospice without walls

a. We will develop new and existing positive collaborative relationships with key stakeholders and partners in order to secure a more joined-up approach to the provision of endo of life care and in doing so maximise the use of our expertise to influence the care that others give.

b. We will embed the National Ambitions for Palliative & End of Life Care framework into the delivery of our services to ensure the needs of people who are living with dying, death and bereavement are met, and that their priorities, preferences and wishes are takin into account at all times.

2. Workforce development

a. We will ensure that our workforce is fit for the future by continually investing in the effective recruitment, development and motivation of staff and volunteers.

b. We will focus on enhancing the well-being and resilience of our staff and volunteers through training, communication and the further development of attitudes, beliefs and values to preserve and reinforce our positive culture.


3. Organisational effectiveness

a. We will develop further our Information Technology (IT) systems to achieve wider connectivity with our external Health and Social Care partners so that up to date vital key patient information is available across different clinical settings at all times.

b. We will adopt the core principles of Information Governance throughout the organisation and by working in collaboration with the NHS achieve the correct level of accreditation to enable us to share information.

c. We will continually adapt and take every opportunity to improve how effectively and efficiently we work, in order to respond to the increasing needs and growing complexity of the care required. We will achieve this by continuing to standardise and simplify all our systems and processes.

d. We will achieve financial stability to enable us to continue to develop our services to meet the growing needs of those we serve, through developing new approaches to fundraising and by investing in innovative and sustainable sources of new income.

e. We will review all our business and support areas to look at reducing our overhead costs, through partnerships or collaboration with other organisations to generate new economies of scale.


APPENDIX B

Relevant Qualifications and Experience Of Key Personnel

Senior Management Team PROFESSIONAL QUALIFICATIONS

Chairman of Trustees

BTEC, ACIPR, National Certificate in Business and Finance

Chief Executive

Chartered Fellow of the CIPD, Diploma in HR Management, MA in Hospice Leadership

Director of Clinical Services/ Deputy Chief Executive

RGN, RMN, BSc, MSc in Palliative Care

Consultant In Palliative Medicine/Medical Director

BA, MB, BChir, MSc, FRCP

Finance Director BA (Hons), part qualified in ACCA, CertITM-PF

Commercial Director Educated to “A” level

PROFESSIONAL QUALIFICATIONS

Head of Quality and Compliance (Registered Manager/ Accountable Officer/ Caldicott Guardian)

RGN, BSc (Hons) , ILM Introductory Diploma in Management, MSc (Oxon), DPhil (Oxon)


TEAM LEADERS PROFESSIONAL QUALIFICATIONS

Deputy Director of Clinical Services and Head of Education

BSc(Hons) Health Studies, PG Dip Ed, MSc Health Informatics, PRINCE2

Head of Inpatient Nursing Services RN1. Dip HE Nursing Studies, BSc (Hons) Nursing Studies

Head of Psychosocial Care Diploma in Social Work and Social Pedagogy, MA in Medicine, Science and Society, ILM Level 5

Head of Community Care BSc (Hons) 1st Class Health Studies, Dip HE Health Studies, PG Cert Leadership Management

Clinical Nurse Specialist in Palliative care (Hospital)

RGN, BSc(Hons) 2:1 in Health Studies, MA (Merit) in Hospice Leadership

Consultant (Hospital) MBBS, BSc, MRCP

Doctor (Hospital) BM MRCGP DCH

Head of HR Associate of CIPD

Organisational Development Manager Chartered Institute of Personnel and Development, MCIPD (including training qualification), Certificate in General HR Practice.

Head of Quality and Compliance/ Registered Manager

RGN, BSc (Hons) Cancer and Palliative Care, ILM Introductory Diploma in Management, MSc EBHC(Oxon), DPhil EBHC (Oxon)

Head of Facilities IOSH Managing Safely, Level 7 Strategic Management and Leadership (CMI), Prince 2 project management, Chartered Manager with the chartered management Institute

Head of IT BA (Hons), Comptia A+, Comptia N+

Head of Financial Reporting Chartered Accountant

Head of Communications and Marketing BA (Hons) Media Studies with IT

Head of Fundraising BA (hons) in European Business with Spanish, MinstF (Cert)

Head of Retail Diploma in Retail Management

All other staff are qualified to the appropriate level for their role.


APPENDIX C

St Luke’s Hospice – Organisation – Board of Trustees

CQ (Chair) Governance Committee

CD (Treasurer) Governance Committee, Finance & Audit (Chair), SLH Ventures Ltd, Organisational Risk & Internal Audit Committee

CG (Vice Chair) Governance Committee, HR & Remuneration & Governance, Income Generation Meeting

SH Clinical Review Group (Chair), Finance and Audit Committee

CC Organisational Risk & Internal Audit Committee (Chair), SLH Ventures Ltd, Income Generation Meeting, Health & Safety Meeting

CPH Clinical Review Group, Finance and Audit Committee

MJ SLH Ventures Ltd (Chair), Income Generation Meeting (Chair), Finance and Audit Committee

JH Governance Committee, HR & Remuneration & Governance (Chair), Clinical Review Group, Health and Safety Meeting

SN HR & Remuneration & Governance

FF Health and Safety Meeting (Chair), Organisational Risk & Internal Audit Committee


Statement of Purpose Policy No: 040

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Appendix E

Complaints Policy August 2016

Summary Information/Record of Approval

Policy Area: Hospice Management

Accountable Person: Chief Executive

Originated by: Head of Quality & Compliance

Signed, Chief Executive:

S Statham

Date: 26/07/16

Latest date of review: August 2019

Document History

Version & Date By Comments

v5 2016/07 Frankie Dee Scheduled update and reformatting

v4 2013/07 Frankie Dee Scheduled update and reformatting

Distribution: Signed original: Policies File in Q&C Office (hard copy) Electronic Copies issued to: Master Policy Folder (docx format) Staff Web Pages

Scope: All staff including volunteers – both clinical and non-clinical areas.



Contents Policy Statement: ........................................................................................................ 20

Accountabilities and Authorities: ................................................................................. 21

Method:....................................................................................................................... 21

Receiving and Reporting the Complaint ........................................................... 21

Acknowledgement of Complaint ....................................................................... 22

Investigation of Complaint ................................................................................ 22

Resolution of complaint .................................................................................... 23

Referral to the Board of Trustees or Care Quality Commission ........................ 23

Compliance: ................................................................................................................ 24

Monitoring and Review: .............................................................................................. 24

Training, Education & Development Required: ........................................................... 25

References: ................................................................................................................ 25

List of Associated Policies: ......................................................................................... 25 Appendix A: Complaints Procedure Flow Chart - Full Version 7 Appendix B: Procedure Flow Chart For Complaints to be Dealt With At Once 9 Appendix C: Complaints Procedure Service User Notice 11



Policy Statement: 1. This policy will ensure effective responses and resolution of complaints,

together with best practice in quality management. 2. The complaint process will be responsive and flexible to address the issues

identified by the complainant. 3. Complaints – whatever their source – will be continuously monitored and used

to improve services, reduce incidents and improve overall quality. Analysis of complaints will contribute to St Luke’s Risk Management processes.

4. All staff will endeavour to resolve any concerns or issues of dissatisfaction as they arise. This will be achieved through a procedure which: a. is accessible to complainants; b. provides a simple system for making complaints about any aspect of the

service provided; c. responds to verbal and written complaints whether made in a formal or

informal manner; d. is a rapid process with designated timescales; e. is open and keeps the complainant informed on the progress of the

investigation; f. is fair to staff and complainants; g. maintains the confidentiality of the patient, complainant and staff

member(s); h. provides the opportunity to learn from complaints to improve services; i. provides instructions on how to manage a complaint from receipt through to

resolution, covering: Investigation of verbal and written complaints; Communication with complainant; Resolution of complaints; Referral to the Care Quality Commission; Links between complaints, governance and quality improvement

procedures.



Accountabilities and Authorities: 5. General responsibilities for this Policy are set out in the Governance Policy. 6. In respect of this Policy, these additional accountabilities and authorities are

established: a. every member of staff is responsible for notifying their line manager of

any complaints they receive b. The recorder of the complaint is responsible for notifying the appropriate

Head of Department (if that person is not already involved) and submitting the written report to the Head of Quality & Compliance at the earliest practicable time.

c. Heads of Departments are responsible for: i. notifying the Chief Executive when appropriate; ii. overseeing the investigation of the complaint; iii. ensuring the complaint is resolved by ensuring that the most appropriate

person: investigates the complaint; responds to the complainant

d. ensuring the outcome is fully reported e. that learning results and appropriate changes in practice are made.

7. The Clinical Review Group will review all complaints concerning clinical practice, advising the Senior Management Team and others as appropriate and reporting findings to the Head of Quality & Compliance.

8. The Strategic Leadership Team will review all non clinical complaints.

9. The Head of Quality & Compliance is responsible for: a. receiving complaint reports; b. requesting Heads of Departments to allocate responsibility for

investigations; c. monitoring progress in responding to complaints; d. analysing complaints, identifying and reporting themes, trends and

associated risks.

Method: (See also the Procedure Flowcharts, Appendix 1)

Receiving and Reporting the Complaint 9. Complaints may be made to any member of staff verbally or in writing by the



patient, or their representative, or any other person aggrieved in connection with St Luke’s services; complaints may be formal or informal.

10. Where it is possible to deal effectively with a complaint at once, this should be done. Responsiveness is very important but it must be remembered that time may be needed for a fully considered and satisfactory response.

11. Details of both verbal and written complaints will be recorded on the Complaints/ Incident/ Near Miss Form, a copy of which will be submitted to the Head of Quality & Compliance as soon as possible.

12. All complaints will be reported as soon as practicable to the appropriate Line Manager, who will notify the Head of Department appropriately. The nature of the complaint will determine how it should be addressed and whether the Chief Executive should also be notified.

13. The complaint will be entered into the Complaints Log database by the Head of Quality and Compliance.

14. Details to be recorded are: a. Nature of complaint b. Area of service concerned c. Date received d. Date resolved e. Who investigated f. Result of the investigation g. Action taken h. Resolution of complaint

Acknowledgement of Complaint 15. All written complaints will receive a written acknowledgement of receipt of their

complaint within 2 working days from the Head of Quality & Compliance or person investigating as appropriate.

16. If a full written reply can be made within 5 working days an initial acknowledgement is not required.

Investigation of Complaint 17. A person will be nominated to investigate the complaint by the appropriate

Director. The nominated person must not be immediately involved in, or the subject of, the complaint.

18. If the complaint relates to clinical matters it will be reported to the Clinical Review Group. Complaints relating to organisational matters will be reported to the Strategic Leadership Team. All complaints will be reported to the Senior Management Team.



19. All findings should be fully documented. Any communication with the complainant should be documented.

20. A full response should be sent to the complainant within 20 working days of receipt of the complaint.

21. If it is not possible to send a full response within the 20 day time scale, a letter explaining the reason for the delay should be sent to the complainant.

Resolution of complaint 23. Once the investigation has been completed a letter should be sent outlining the

findings and the proposed action to be taken. 24. The Head of Quality & Compliance must be notified of the findings of the

complaint together with the action to be taken, for entry in the complaint database and copied into the response.

25. Action plans following the complaint should be completed together with a time scale for action and review; this will involve the staff concerned whenever possible.

Referral to the Board of Trustees or Care Quality Commission 27. If the complainant is unhappy with the outcome of the complaint, s/he can

complain to the Board of Trustees and/or Care Quality Commission. If the complaint is about a fundraising matter, this can be made to the Fundraising Standards Board.

28. Details of how to complain are provided in the Patient Information leaflet on ‘How to Complain’

29. An independent review by the Board or Trustees may be appropriate (See the Information Sheet for Service Users, Appendix C)



Compliance: 30. This Policy complies with the Health & Social Care Act 2008 (Regulated

Activities) Regulations 2014

Monitoring and Review: 31. This Policy will be reviewed every 3 years by the Senior Management Team or

when legislation requires, whichever is sooner. 32. A report will be made to the Care Quality Commission as requested, including:

a. the complaints made; b. the numbers resolved. c. whether there has been compliance with this policy.

33. A six-monthly complaints report will be submitted to the Board of Trustees. 34. A monthly report will be reviewed by the Senior Management Team. 35. Clinical complaints will be reported to the Clinical Review Group every 2

months. 36. A twice-yearly analysis of complaints will be made for the purpose of identifying

systematic risks to the organisation. This will be reported to the Organisational Risk and Internal Audit Committee



Training, Education & Development Required: 38. Training will be provided to all staff in the organisation on:

a. what is a complaint, particularly informal complaints, and the ways in which they may be expressed;

b. how to receive a complaint; c. how to deal with someone making a complaint; d. the complaints process.

39. This will be provided as a video on the Intranet.

References:

Ref No. Source

1 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014.

List of Associated Policies: Confidentiality Policy Clinical Governance Policy Governance Policy Risk Management Policy



Appendix A

Complaints Procedure Flow Chart

Full Version



Appendix B

Complaints Procedure Flow Chart For

Complaints that can be Dealt With At Once



Complaint Received (Day 0)

Flowchart: Procedure for Complaints that can be dealt with at once

Complete a Complaint form

Submit copy of Complaint Form to Head of Quality &

Compliance

Notify Line Manager

Investigate Complaint

Give verbal response to Complainant

Draft letter of response for

signature by HoD

Does Complainant want a written

response?

Notify Head of Q&C of response

Update Complaints Log

NO

Letter to Complainant by Day 5. Copy to Head of Q&C

YESNotify HoD



Appendix C

Complaints Procedure

Service User Notice


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